Provider Demographics
NPI:1356508535
Name:ST ROSE YOUTH & FAMILY CENTER INC
Entity Type:Organization
Organization Name:ST ROSE YOUTH & FAMILY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF TREATMENT AND COMM SVC
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:J
Authorized Official - Last Name:WALDRON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:414-466-9450
Mailing Address - Street 1:3801 N 88TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-2706
Mailing Address - Country:US
Mailing Address - Phone:414-466-9450
Mailing Address - Fax:414-466-0730
Practice Address - Street 1:3801 N 88TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-2706
Practice Address - Country:US
Practice Address - Phone:414-466-9450
Practice Address - Fax:414-466-0730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI265012322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43017200Medicaid